Optimizing inhaler use by pharmacist-provided education to community-dwelling elderly

Accepted Manuscript Optimizing inhaler use by pharmacist-provided education to community-dwelling elderly Carla Bouwmeester, PharmD, BCPS, Jacqueline Kraft, PharmD, Kathleen M. Bungay, PharmD, MS PII:

S0954-6111(15)30028-7

DOI:

10.1016/j.rmed.2015.07.013

Reference:

YRMED 4755

To appear in:

Respiratory Medicine

Received Date: 28 January 2015 Revised Date:

14 July 2015

Accepted Date: 17 July 2015

Please cite this article as: Bouwmeester C, Kraft J, Bungay KM, Optimizing inhaler use by pharmacistprovided education to community-dwelling elderly, Respiratory Medicine (2015), doi: 10.1016/ j.rmed.2015.07.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Optimizing inhaler use by pharmacist-provided education to community-dwelling elderly Authors:

PharmD, MS ad

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Corresponding Author: Carla Bouwmeester, PharmD, BCPS Northeastern University, Bouvé College of Health Sciences, School of Pharmacy 360 Huntington Avenue, R218TF Boston, MA 02118 Voice: +1-617-947-2037 (mobile) Fax: +1-(617) 373-7655 [email protected]

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Carla Bouwmeester, PharmD, BCPS ab, Jacqueline Kraft, PharmDc, Kathleen M. Bungay,

Northeastern University, Bouvé College of Health Sciences, School of Pharmacy, 360 Huntington Avenue, R218TF, Boston, MA, USA 02115 [[email protected]] b

Elder Service Plan of the Harbor Health Services, 1135 Morton Street Mattapan, MA, USA 02126

c

Permanent address: Harvard Vanguard Medical Associates, 485 Arsenal Street, Watertown, MA, USA 02472, [email protected] d

Permanent address: Center for the Evaluation of Value and Risk in Health (CEVR), The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Boston, MA 02111

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ABSTRACT OBJECTIVE: To assess, using a standard observational tool, the ability of patients to

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demonstrate and maintain proper inhaled medication administration techniques following pharmacist education.

SETTING: Patient’s homes or adult day health center.

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DESIGN: Six-month observational study.

PARTICIPANTS: Patients in a Program for All-inclusive Care for the Elderly (PACE)

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prescribed one or more inhaled medications used at least once daily. INTERVENTION: Instruction by on-site clinical pharmacist.

MEASUREMENTS: Hickey’s Pharmacies Inhaler Technique assessment (score range: 0-20, higher better).

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RESULTS: Forty-two patients were evaluated at baseline, taught proper techniques for using inhaled medications, assessed immediately following the education, and re-assessed 4-6 weeks later. The mean pre-assessment score was 14 (SD 4.5, range 0-20), the initial post-assessment

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score increased to 18 (SD 3, range 10-20). The second post-assessment (4-6 weeks later) score mean was 17.7 (SD 3, range 10-20). Both follow-up scores were significantly improved from

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baseline (p<0.05). Multivariable analysis indicated the strongest predictors of second posttraining score were: score after initial pharmacist training and being subscribed to auto-refill. These characteristics predicted ~ 70% of the variance in the second score (p <0.001). CONCLUSIONS: These results indicate that education by a pharmacist combined with an autorefill program can improve and sustain appropriate inhaler use by community-dwelling elders in a PACE program. The improved score was maintained 4-6 weeks later indicating a sustained

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benefit of medication administration education. Optimal inhaler use ensures optimal dosing and supports appropriate inhaler treatment in lieu of oral agents.

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Keywords: inhaler use, COPD, asthma, pharmacist, education, PACE, elderly

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INTRODUCTION

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Lower respiratory diseases including chronic obstructive pulmonary disease (COPD) and asthma are common in the elderly and impart a substantial economic burden on individuals and society. The Centers for Disease Control and Prevention (CDC) estimates that COPD affects 22-26% of

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older adults and that asthma is seen in 3 million persons over the age of 65.[1,2] The National Heart, Lung, and Blood Institute estimates the total (direct and indirect) annual cost of COPD,

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asthma and pneumonia in the US was $ 106 billion in 2009.[3] Optimizing treatment of COPD and asthma is likely to reduce the clinical and financial strain imposed by these diseases.

Inhaled medication therapy is currently the mainstay of treatment for both COPD and asthma. When used appropriately, this mode of administration allows maximal drug delivery to the lungs

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with minimal systemic absorption and side effects.[4] Despite the advantages of this mode of drug administration, many studies report suboptimal inhaler technique with all device types including metered-dose inhalers (MDIs), MDI use with spacer devices, and breathe-actuated dry

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powder inhalers (DPIs).[5-8] Poor patient self-administered inhaler technique is often related to

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poor outcomes such as increased emergency room visits, use of short-course steroids, antimicrobial use, and poor disease control.[5]

Using an inhaler appropriately requires a certain degree of coordination and dexterity. Older patients are more likely to have conditions such as arthritis, which affect physical movement and coordination. Cognitive function also affects the ability to correctly use inhaler devices. Published predictors of poor inhaler technique in the elderly include Mini Mental State

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Examination (MMSE) scores less than 24, dyspraxia, decreased hand strength, and executive function deficits.[9-12]

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Many patients in all types of settings receive initial inhaler training from physicians, nurses, and pharmacists. Yet, several studies have shown that patients often exhibited suboptimal technique in as little as three days after initial training.[6,13] Assessing a patient’s ability to correctly use

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an inhaled medication is frequently based on checklists [7,8,14-16] or essential steps described in manufacturer instructions and national guidelines. However, there is no standardized checklist

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for technique assessment used across research studies in the United States.[17]

In this article we describe, using a standard education and assessment process, the ability of community-dwelling elderly patients currently taking chronic inhaled medications to

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demonstrate and maintain proper administration techniques following education by a pharmacist. Additionally, we describe, using a multivariable linear regression analysis, the strongest

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METHODS

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predictors of patients’ retained knowledge of optimal inhaler technique.

Participants

Participants were all enrolled in a Program of All-Inclusive Care for the Elderly (PACE)e. To be eligible to participate in any PACE program, one must meet all of the following criteria: 1) age at least 55 years or older, 2) certified by their state to need nursing home level of care, 3) able to live safely in the community at the time of enrollment, and 4) reside in a PACE service area. e

There is a national PACE Association whose information can be found at www.npaonline.org.

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Our sample was drawn specifically from the patients in Elder Service Plan (ESP) of Harbor Health Services, Inc., in Mattapan, MA a suburb of Boston. Participants who resided at home or in an assisted living facility (ALF) were considered eligible for inclusion. Data for additional

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inclusion criteria were obtained from the EMR from this specific PACE program. We identified those participants (patients) who, as indicated in the EMR, were on inhaled medications for COPD and/or asthma. Next, we refined the sample to include those patients who were on

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regularly scheduled (i.e. maintenance) inhalers. Patients on both maintenance inhalers and PRN (as needed) inhalers were included in the study, however, the assessment focused on the patient’s

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use of the maintenance inhaler. Individuals were excluded if they lived in a rehabilitation or long-term care facility (LTC), if they moved to one of these facilities during the study, or if their inhaler was discontinued during the study. To be included, participants must have been prescribed at least one regularly scheduled inhaled medication for management of asthma and /

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or COPD. Persons enrolled in the Elder Service Plan PACE have their prescription medications filled by one pharmacy with which the program has a contractual agreement. This arrangement provided reliable means to verify drug, dose, frequency, and refill information. Persons

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prescribed only ‘as needed’ inhalers and patients receiving inhaled medications as a nebulized solution were excluded from the study. Northeastern University Institutional Review Board

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approved this study.

Study Design

Study participants met with a pharmacist and/or student pharmacist twice during the study period; on enrollment and 4 to 6 weeks later. The initial and follow-up visits occurred at the Elder Services Program Adult Day Health Center or in the patient’s home based on patient

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preference and pharmacist availability. During the initial visit patients were provided with a placebo demonstration device of their prescribed inhaler(s) (e.g., discus, dry powder inhaler, etc.). First, patients were asked to demonstrate how they currently used the device(s). As

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participants demonstrated use, the pharmacist quietly observed and scored the patients’ technique using a 10-item, device-specific assessment tool (See online supplement for inhaler

assessment tools) [18]. Next, the pharmacist used device-specific training tool prompts to teach

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patients how to correctly use each inhalation device. Each step was repeated until the participant demonstrated understanding before moving to the next step in the administration process.

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Training tools and assessment tools were paired; there was a written set of instructions named, A Guide to ‘Using Your Diskus’ and an assessment tool called ‘Diskus Use Assessment’. Following training, participants were again asked to demonstrate how to use the inhaler(s). A score was recorded for patients’ performance on the assessment tool (Assessment #1). During the

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follow-up visit participants were once again asked to demonstrate using the placebo inhaler while the pharmacist evaluated and scored the patients’ technique (Assessment #2). The same pharmacist, who conducted the first assessment, conducted the follow up as well. The

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assessment.

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pharmacist overseeing the study directly supervised all students involved in teaching and

Measures

Data on the following measures were obtained prior to the first intervention: age, diagnosis for the inhaled medication(s), living arrangement, location where the inhaler was stored and the amount of assistance provided, if any, when using an inhaler. Two examples of assistance are Self-Administered Medication Management (SAMM) and medication cueing. SAMM is a

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medication reminder service provided in Assisted Living Facilities (ALF) where an aide comes to the patient’s room at the appropriate administration time and gives them their medications. The aide cannot assist with medication administration but can only hand the patient their inhaler

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(or pills). Medication cueing differs from SAMM and is defined as verbal reminders regarding proper inhaler administration. This may be performed by a caregiver in the home setting or by a nurse in an ALF that provides limited medication management. The name, dose and frequency

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of every inhaler prescribed, and refill history was confirmed by the contract pharmacy.

Individuals enrolled in an automatic refill program were noted as such. Cognitive function based

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on the most recently documented mini-mental state exam (MMSE) was noted. The primary outcome measure was the score from a 10-item, device-specific assessment tool adapted from Hickey’s Pharmacies Inhaler Assessments [18] indicating the amount of knowledge about inhaler use technique. Companion tools (teaching techniques and assessments)

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were used. The choice of these tools was based on a review of published English language literature that revealed overlapping assessment items in multiple variations of checklists. [7,1416,19] We chose the most comprehensive tool that included assessment points contained in all

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previously identified tools that we researched. This assessment tool allows an individual item

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score from 0 (poor) to 2 (best) on each of 10 steps involved in using an inhaler. During the initial visit with a pharmacist, the assessment scores were documented before and after patient education. Technique was assessed and scored once during the follow-up visit with the patient.

Analytic Methods Data was analyzed using STATA version 12.[20] Simple descriptive measures of the variables were calculated. Continuous variables are represented as mean ± standard deviations. Student’s t-

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test and chi-square, depending on the distribution of the data, were used to test for differences such as patient scores on the summed 10-item assessment tool-checklist at different time points. A variable was derived to represent the inhaler burden (burden = total number of inhalations for

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all inhalers per day). A burden of 1 inhalation once per day equals 1 (the lowest) and two

inhalations four times per day with 2 inhalations twice daily equals 12 (the highest). MMSE was tested as a continuous and as a categorical variable. A normal MMSE was defined as a score of

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25 to 30. Mild cognitive impairment was a MMSE score of 20 to 24, moderate impairment was

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11 to 19 and severe cognitive impairment was defined as a score of 10 or lower.[21]

Multivariable linear regression was used to test for the influence of known variables on the primary outcome variable – the score for knowledge of inhaler use techniques. Each known patient characteristic was tested individually to determine the relationship to the primary (initial

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assessment score) and secondary outcome measure(s) listed in Table 1. A multivariable model was constructed for the outcome measure of retained knowledge of inhaler technique using variables added in a stepwise manner; significant variables (p<= 0.10) were retained in the model

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and are presented at the beta coefficient. Variance was calculated for the final model and is

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reported as the R-squared statistic.

RESULTS

Fifty-two eligible patients were invited by the pharmacist to participate in the trial, and 47 agreed to do so. Three people were unable to complete the study due to hospitalization and 2 others had their inhaler discontinued after the first assessment. The 42 people who completed the study had a mean age of 82 years (range: 58-97). Most patients (79%) were prescribed one or more inhaled

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medications for treatment of COPD. The mean Mini Mental State Exam (MMSE) score upon enrollment was 24 (range: 9-30). One patient had a MMSE suggesting severe cognitive

displayed in Table 1.

Table 1: Baseline Characteristics (n=42)

Data 81 (10.95)

Age, mean yrs (SD) Diagnosis (es), # patients (%)

33 (79) 2 (0.5) 3 (0.7) 4 (9.5) 24 (9-30)

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COPD² Asthma COPD and Asthma None recorded MMSE³ Score at Enrollment, mean (range) MMSE Categories # patients (%) No Impairment (score 25-30) Mild (score 20-24) Moderate (score 11-19) Severe (score < = 10) Other Medication Administration Characteristics Self-Admin Med Mgmt (SAMM±), # patients (%) Medication Cueing, # patients (%) Automatic Inhaler Refills, # patients (%) ² COPD is Chronic Obstructive Pulmonary Disease

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Characteristic

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impairment; 19 patients had mild to moderate impairment. Baseline patient characteristics are

19 (45) 15 (36) 6 (14) 1 (2) 27 (68) 7 (19) 25 (60)

³ MMSE is Mini Mental State Exam

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± SAMM is Self-Administered Medication Management (conducted in Assisted Living Facilities)

Participants used eight different inhalers at doses ranging from 1 inhalation once daily to 2 inhalations four times daily. Table 2 contains a list of the inhalers used and the frequency amongst the 42 participants. Advair Diskus (fluticasone / salmeterol) and Spiriva HandiHaler (tiotropium bromide) were the most frequently used inhaled medications. The median inhaler

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burden (sum of inhalations per day multiplied by frequency of use per day for all devices) was 2 (range: 1-12). Most patients used one inhaler twice daily

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Table 2: Frequency of Inhaler Use‡

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Inhaler Ingredients # Patients (%) Fluticasone/ salmeterol 18 (42.9) Tiotropium bromide 17 (40.5) Ipratropium/ albuterol sulfate 7 (16.7) Fluticasone propionate 5 (11.9) Albuterol sulfate 2 (4.8) Budesonide/ formoterol fumarate 2 (4.8) Ipratropium bromide 1 (2.4) ‡ Total number does not add up to number of patients (n=42) because some patients were using more than one inhaler.

On average, a pharmacist spent approximately 30 minutes evaluating each patient and teaching them about the proper use of inhalation devices. The outcomes of the pharmacists' teaching,

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measured by a standard assessment-checklist are summarized in Table 3. The mean preassessment score was 14 (SD 4.5, range 0-20). After completing the training, the mean assessment score was significantly increased to 18.2 (SD 2.9, range 10-20) (p< 0.001). Upon re-

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testing in 4 to 6 weeks, the post-assessment score mean remained increased from the post training assessment at 17.7 (SD 3.1, range 10-20) (p < 0.001). The mean difference between pre-

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and post-assessment scores was 3.7 (SD 3.3).

Table 3: Outcomes of Inhaler Technique Education by a Pharmacist

Baseline (pre-training) Assessment 1 (post-pharmacist training) Assessment 2 (4-6 weeks post pharmacist training) *Scale ranges from 0 (poor) to 20 (best)

Inhaler Technique Score* mean (SD) 14.0 (4.5) 18.2 (2.9) 17.7 (3.1)

p < 0.001 NS

p < 0.001

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Multivariable linear regression analysis (Table 4) indicated that the strongest predictors of the second post-training assessment score, or ‘Retained Knowledge’ were: (1) the score after initial

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pharmacist training, and (2) being subscribed to an auto-refill program. These two characteristics predicted approximately 71% of the variance in the second score (p<0.001). MMSE score predicted retained knowledge when tested independently but was not significant in a

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multivariable model with variables representing the score after initial training and being

subscribed to auto-refill. Multivariable linear regression analysis also revealed that the following

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variables were not uniquely significant predictors of retained knowledge: residing on a dementia unit, medication reminders provided by ALF staff for patients on SAMM, medication cueing, age, and MMSE score.

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Table 4: Determinants of Retained Knowledge by Multiple Variable Linear Regression Analysis Independent Variable β P value R2 Overall Model 0.706* Constant 1.41 0.445 Score post initial training 0.82 0.001 Subscribed to an Auto Refill of Inhaler 2.07 0.001

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DISCUSSION

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β = standardized beta regression coefficient, R2 represents overall model, *p<0.001

We undertook the present study to determine if a structured educational intervention would be adequate to teach elderly patients appropriate inhaler skills that would be retained over time. We also tested the variables that may contribute to effective, long-lasting patient education. We found that, on average, elderly patients who were re-educated by a pharmacist about the use of an inhaled medication had a significantly increased assessment score following one in-person training session. Furthermore, these patients retained that knowledge at 4 to 6 weeks post-

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education. Our study suggests that as many patients as possible should receive inhaler training and education by a pharmacist given that most will benefit.

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Previous studies have found an association between MMSE score and inhaler technique.[11] When tested as the only independent variable in our study the same significant finding was true. However, when included in a multivariable analysis, the association of technique score and

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from additional education, regardless of cognitive function.

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cognitive function was no longer significant, again suggesting that most patients would benefit

None of the patients enrolled in this study were newly started on an inhaler; all were already prescribed an inhaler for routine use. We hypothesize that even patients who have been using inhaled medications regularly can benefit from an educational intervention. All patients,

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regardless of inhaler burden (total puffs per day) were susceptible to improvement in inhaler use technique through education. Assistance provided to patients via medication reminders (ie SAMM) or medication cueing was not significantly associated with retained knowledge. We

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suspect this may be due to the high percentage (68%) of patients receiving assistance making it difficult to identify any significant association. This leads to the hypothesis that a structured

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educational intervention should be attempted before abandoning inhalers for oral medications in elderly patients. Prolonging the benefits of inhaled medications by optimizing user technique delays the need for oral medications and the associated inherent risks.

The significant association between having inhaled medications automatically refilled by the pharmacy and the patients’ inhaler technique score may be explained in several ways. Auto-refill

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may be a partial surrogate for medication adherence, and/or patients who have uninterrupted access to their inhalers may continue to use them thereby retaining proper technique. The autorefill service is unique to our program, but other chain pharmacies are now offering various

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forms of this as well. For our PACE program, all patients receive their oral tablets/capsules in monthly ‘Medicine-On-Time’ bubblepacks. These bubblepacks are automatically delivered every month and replaced during the month as needed when medication changes are made (i.e.,

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new drug or increase/decrease dose of current medication). Medications are continually sent on a monthly basis until the medical provider contacts the pharmacy with a discontinuation order.

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All medications are reviewed by the medical providers at least yearly and reconciled with the pharmacy. Any medication that is not a tablet/capsule cannot be placed in a bubblepack and must be dispensed separately. This includes dosage forms such as: inhalers, creams, ointments, eyedrops, nebulized solutions, enemas, lozenges, and oral liquid medications. When the

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providers in our PACE program send a prescription to the pharmacy for one of these dosage forms, they must specify in the comments section of the prescription (via the EMR) that the medication should automatically be filled and delivered each month together with the patient’s

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bubblepacks.

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The impetus for this study was an observation that many patients were “stockpiling” their inhalers because they were on autorefill and were unable to use the inhalers correctly. During our home visits and according to information from the pharmacy we found that only 4 patients had an excess supply of inhalers. It is now our common practice to include all inhalers on autorefill (except PRN rescue inhalers). Everyone is eligible for autorefill and patients are enrolled by the prescribers at the time the prescription is written. Based on results from the study described in

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this manuscript, the clinical pharmacists now notify providers if they forgot to include autorefill on a particular inhaler prescription.

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Most previous studies have been conducted in hospital settings where patients are initially educated about inhaler use at the same time they are burdened with other discharge

instructions.[9,10,15,22,23] These studies show that patients do not retain inhaler education. Our

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study was conducted in the community, often in patient’s homes. Our results suggest that

patients educated in a more familiar environment are more likely to retain what they learn from

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an educational intervention. We believe the reason our study showed positive results was because patients were in the comfort of their homes where they could focus on the education rather than trying to also get through the pharmacy pick-up line or focusing on getting

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discharged from the hospital.

Our work suffers from a few limitations. This was an observational study conducted within one PACE program site near Boston; this can suggest the possibility of a unique patient population

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and thus limit the generalizability to other sites. There were two registered pharmacists, one of whom conducted most of the teaching and supervised the 5 student pharmacists who were

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involved; overall there were a relatively small number of pharmacist-interveners. In future, larger studies the fidelity of the intervention will need to be confirmed.

The study offers interesting information for further study on whether pharmacists’ direct patient education is a unique and positive contribution to retaining knowledge about how to appropriately use self-administered inhalers. The study also points to the need for patients to be

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re-educated about inhaler use, initial education and training at the point of the first prescription may not suffice. Additionally, possibly repeated use, or good adherence seems to be related to better technique and to retained knowledge; patients improve with sustained, proper use of their

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inhalers.

CONCLUSION

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Our data show that a structured teaching session delivered by pharmacists is sufficient to produce

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a sustained improvement in knowledge and handling of inhalers by community dwelling elders.

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ACKNOWLEDGMENTS The authors acknowledge the contributions of the older people who inspired and participated in

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this study and the Elder Service Plan of Harbor Health Services, Inc. for their contributions to the

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pharmacists.

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APPENDIX

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Pharmacist Inhaler Use Education

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TABLES Table 1: Baseline Characteristics (n=42) Age, mean yrs (SD) Diagnosis (es), # patients (%)

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³ MMSE is Mini Mental State Exam

33 (79) 2 (0.5) 3 (0.7) 4 (9.5) 24 (9-30)

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COPD² Asthma COPD and Asthma None recorded MMSE³ Score at Enrollment, mean (range) MMSE Categories # patients (%) No Impairment (score 25-30) Mild (score 20-24) Moderate (score 11-19) Severe (score < = 10) Other Medication Administration Characteristics Self-Admin Med Mgmt (SAMM±), # patients (%) Medication Cueing, # patients (%) Automatic Inhaler Refills, # patients (%) ² COPD is Chronic Obstructive Pulmonary Disease

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Data 81 (10.95)

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Characteristic

19 (45) 15 (36) 6 (14) 1 (2)

27 (68) 7 (19) 25 (60)

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± SAMM is Self-Administered Medication Management (conducted in Assisted Living Facilities within study’s PACE program)

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Table 2: Frequency of Inhaler Use‡

# Patients (%)

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Fluticasone/ salmeterol 18 (42.9) Tiotropium bromide 17 (40.5) Ipratropium/ albuterol sulfate 7 (16.7) Fluticasone propionate 5 (11.9) Albuterol sulfate 2 (4.8) Budesonide/ formoterol fumarate 2 (4.8) Ipratropium bromide 1 (2.4) ‡ Total number does not add up to number of pa%ents (n=42) because some patients were using more than one inhaler.

RI PT

Inhaler Ingredients

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Table 3: Outcomes of Inhaler Technique Education by a Pharmacist Inhaler Technique Score* mean (SD) p < 0.001 NS

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*Scale ranges from 0 (poor) to 20 (best)

14.0 (4.5) 18.2 (2.9) 17.7 (3.1)

p < 0.001

RI PT

Baseline (pre-training) Assessment 1 (post-pharmacist training) Assessment 2 (4-6 weeks post pharmacist training)

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Table 4: Determinants of Retained Knowledge by Multiple Variable Linear Regression Analysis

AC C

EP

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Independent Variable β P value R2 Overall Model 0.706* Constant 1.41 0.445 Score post initial training (Assessment #1) 0.82 0.001 Subscribed to an Auto Refill of Inhaler 2.07 0.001 β = standardized beta regression coefficient, R2 represents overall model, *p<0.001

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Highlights Pharmacists assessed and trained community-dwelling elderly on inhaler technique Assessment scores after training and 4-6 weeks later showed significant improvement

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Predictors of retained knowledge were automatic refill and initial assessment score MMSE was significant as an independent variable but not in the multivariate analysis

AC C

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TE D

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Education by a pharmacist can improve and sustain appropriate inhaler use

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Using a Diskus Inhaler These steps should be assessed when a patient is using this inhaler. • Column 1: observe the patient using their inhaler before providing any teaching • Column 2: provide a score regarding how the patient is able to complete each direction during teaching session • Column 3: observe the patient using their inhaler during follow-up to see if teaching was retained

RI PT

Please record the date at the top of each column. If assessing technique score 0, 1 or 2 depending on whether the step is not completed (0), done but not entirely correctly (1) , or completed correctly (2). If patient receives a 1, please provide what patient did to prevent them from getting 2 points.

Score

Date Date Date

2

SC

Hold the outer casing in one hand and push the thumb grip away with other hand until it snaps into place Comments: Hold level and slide lever away until it clicks (dose is now ready) Comments:

1

4

Hold the Diskus flat Comments:

5

Put mouthpiece between lips Comments:

6

M AN U

Breathe out gently away from the device Comments:

3

Breathe in steadily and deeply Comments: Remove from mouth and hold breath for 10 seconds Comments:

7

Breathe out slowly

TE D

8

Comments: 9

To close, slide thumb grip back towards you as far as it will go until it clicks Comments:

EP

If a second dose is required, wait a minimum of 30 seconds before repeating the process. (If a second dose is not required, reviewer adds 2 point to score.) ** Comments:

10

Total/20

AC C

** Rinse out mouth after using a steroid inhaler**

Patient Name: Patient Address: Date performed and by whom: Initial observation: Training: Final observation: Remaining day supply:

Inhalers accessible: SAMM:

Y/N Y/N

Cueing:

Y/N

Recommendations: (i.e. use spacer)

Adapted from Hickeys Pharmacies Inhaler Technique Assessments: Updated April 2010

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Using a Handihaler These steps should be assessed when a patient is using this inhaler. • Column 1: observe the patient using their inhaler before providing any teaching • Column 2: provide a score regarding how the patient is able to complete each direction during teaching session • Column 3: observe the patient using their inhaler during follow-up to see if teaching was retained

Score Date Date Date

RI PT

Please record the date at the top of each column. If assessing technique score 0, 1 or 2 depending on whether the step is not completed (0), done but not entirely correctly (1) , or completed correctly (2). If patient receives a 1, please provide what patient did to prevent them from getting 2 points. Press green button and open lid of device exposing mouthpiece Comments:

2

Open the mouthpiece to reveal the capsule cavity Comments: Remove the capsule from the blister only immediately before use and place the capsule in the centre chamber Comments: Close the mouthpiece firmly until you hear a click Comments:

3 4 5

M AN U

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1

Hold the inhaler with mouthpiece upwards Comments:

6

Press piercing button completely in once and then release Comments:

7

Breathe out completely (not in mouthpiece) then place mouthpiece in mouth

TE D

Comments: Breathe deeply to hear the capsule vibrate until the lungs are full and hold breath as long as comfortable Comments:

8

Resume normal breathing then repeat steps 7 to 9 once, after a break of 30 seconds Comments:

10

Open the mouthpiece again to tip out the used capsule and dispose Comments:

EP

9

AC C

Total/20

Patient Name: Patient Address: Date performed and by whom: Initial observation: Training: Final observation:

Recent medical changes: Recommendations: (i.e. use spacer)

Adapted from Hickeys Pharmacies Inhaler Technique Assessments: Updated April 2010

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Using a Meter Dosed Inhaler (MDI) The following steps should be followed when using this inhaler. • Column 1: observe the patient using their inhaler before providing any teaching • Column 2: provide a score regarding how the patient is able to complete each direction during teaching session • Column 3: observe the patient using their inhaler during follow-up to see if teaching was retained

Remove cap Comments:

2

Shake inhaler Comments:

3

Breathe out gently Comments:

4

Hold inhaler upright Comments:

5

Put mouthpiece in mouth, close lips and teeth around it Comments: Breathe in slowly and deeply Comments: Press canister down, continue to inhale deeply Comments:

9 10

M AN U

Remove mouthpiece from mouth and hold breath for 10 seconds Comments: Breathe out slowly Comments:

TE D

8

If a second dose is required at this point, wait a minimum of 30 seconds before repeating steps 2 to 9. (If a second dose is not required at this point reviewer adds 2 point to score.) Comments:

EP

7

Date Date Date

SC

1

6

Score

RI PT

Please record the date at the top of each column. If assessing technique score 0, 1 or 2 depending on whether the step is not completed (0), done but not entirely correctly (1) , or completed correctly (2). If patient receives a 1, please provide what patient did to prevent them from getting 2 points.

AC C

Total/20

**Rinse out mouth after using a steroid inhaler**

Patient Name: Patient Address: Date performed and by whom: Initial observation: Training: Final observation: Recent medical changes: Recommendations: (i.e. use spacer)

Adapted from Hickeys Pharmacies Inhaler Technique Assessments: Updated April

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Using a MDI with Spacer These steps should be assessed when a patient is using this inhaler. • Column 1: observe the patient using their inhaler before providing any teaching • Column 2: provide a score regarding how the patient is able to complete each direction during teaching session • Column 3: observe the patient using their inhaler during follow-up to see if teaching was retained

Score Date Date Date

1 2

3

Press the canister once to release a dose of the drug Comments: Without delay, take a deep, slow breath in Comments:

5 6

Hold breath for 10 seconds Comments:

7

Breathe out through the mouthpiece Comments:

8

M AN U

4

SC

RI PT

Please record the date at the top of each column. If assessing technique score 0, 1 or 2 depending on whether the step is not completed (0), done but not entirely correctly (1) , or completed correctly (2). If patient receives a 1, please provide what patient did to prevent them from getting 2 points. Remove cap from inhaler Comments: Shake inhaler and insert into the spacer Comments: Place mouthpiece in mouth, and close lips and teeth around it Comments:

Breathe in again without pressing the canister

Remove the mouthpiece from the mouth and then breathe out Comments: If a second dose is required at this point, wait a minimum of 30 seconds before repeating stages 2 to 9. (If a second score is not required at this point reviewer adds 2 point to score.)** Comments:

10

EP

9

TE D

Comments:

Total/10

AC C

** Rinse out mouth after using a steroid inhaler**

Patient Name: Patient Address: Date performed and by whom: Initial observation: Training: Final observation:

Recent medical changes: Recommendations: (i.e. use spacer)

Adapted from Hickeys Pharmacies Inhaler Technique Assessments: Updated April 2010

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Using a Turbuhaler These steps should be assessed when a patient is using this inhaler. • Column 1: observe the patient using their inhaler before providing any teaching • Column 2: provide a score regarding how the patient is able to complete each direction during teaching session • Column 3: observe the patient using their inhaler during follow-up to see if teaching was retained

Unscrew and lift off the white cover Comments:

2

Hold Turbuhaler upright Comments:

3

Twist grip forwards and backwards as far as it will go Comments:

4

Twist grip backwards until a click is heard Comments:

5

Breathe out gently

6

Put mouthpiece between teeth with lips around it

7

Breathe in quickly and deeply Comments:

8

Remove from mouth and hold breath for 10 seconds Comments:

9

Breathe out slowly

10

If a second dose is required, wait a minimum of 30 seconds before repeating the process. (If a second dose is not required, reviewer adds 2 point to score.) ** Comments:

Date Date Date

EP

TE D

M AN U

SC

1

Total/20

Score

RI PT

Please record the date at the top of each column. If assessing technique score 0, 1 or 2 depending on whether the step is not completed (0), done but not entirely correctly (1) , or completed correctly (2). If patient receives a 1, please provide what patient did to prevent them from getting 2 points.

** Rinse out mouth after using a steroid inhaler**

AC C

Patient Name: Patient Address: Date performed and by whom: Initial observation: Training: Final observation:

Recent medical changes: Recommendations: (i.e. use spacer)

Adapted from Hickeys Pharmacies Inhaler Technique Assessments: Updated April 2010